A new report from the House Committee on Oversight and Accountability reveals that pharmacy-benefit managers (PBMs) are directing patients toward more expensive medications while also restricting their options for obtaining these drugs. The report is the result of a 32-month investigation by the committee and coincides with an upcoming hearing featuring executives from some of the largest PBMs in the country.
PBMs serve as intermediaries for prescription drug plans, negotiating prices with pharmaceutical companies on behalf of health insurers and determining out-of-pocket costs for patients. The three largest PBMs in the United States—Express Scripts, OptumRx, and Caremark—handle approximately 80% of all prescriptions.
According to the findings, PBMs have established preferred drug lists that often prioritize higher-priced brand-name medications over more affordable alternatives. For instance, emails from Cigna staff discouraged the use of less expensive alternatives to Humira, a drug for arthritis and autoimmune conditions that was priced at $90,000 annually, despite the availability of a biosimilar at half that cost.
Additionally, the committee’s report highlighted practices by Express Scripts, which informed patients that they would incur higher costs when filling prescriptions at local pharmacies compared to obtaining a three-month supply from its affiliated mail-order service. This policy effectively limits patients’ pharmacy choices.
Earlier this month, the U.S. Federal Trade Commission (FTC) issued a comparable report noting that increased integration among PBMs has allowed the largest six to manage nearly 95% of all prescriptions in the country. The FTC expressed concern over the substantial influence PBMs have over Americans’ access to affordable medications, suggesting that this creates a scenario where vertically integrated PBMs might favor their affiliated businesses, leading to conflicts of interest that negatively impact independent pharmacies and contribute to rising drug costs.
FTC Chair Lina M. Khan commented on the findings, indicating that these middlemen have been overcharging patients for cancer medications, generating excess revenue exceeding $1 billion.